Common use of Network Providers Clause in Contracts

Network Providers. If you seek covered health care services from a BlueCHiP provider, you will only be responsible for your deductible, copayment, and/or the difference between the maximum benefit and our allowance if any, which may apply to a covered health care service. To see if a provider is a BlueCHiP provider, check your BlueCHiP Coordinated Health Plan Provider Directory, call our Customer Service Department at (401) 274-3500 or ▇-▇▇▇-▇▇▇-▇▇▇▇ or TDD (▇▇▇) ▇▇▇-▇▇▇▇ or ▇-▇▇▇-▇▇▇-▇▇▇▇, or visit our Web site ▇▇▇▇▇▇▇▇.▇▇▇ If you are outside the local area you may seek covered health care services from a provider who participates with the BlueCard traditional indemnity network (a BlueCard provider). When you do so, you will only be responsible for your deductible, copayment, and/or the difference between the maximum benefit and the allowance (if any) based on the amount due under the BlueCard program policies. See Section 5.3 for more information on the BlueCard program. To see if a provider is a BlueCard provider, call BlueCard Access at the number shown on your BlueCHiP ID Card ▇-▇▇▇-▇▇▇ BLUE (2583) or visit ▇▇▇.▇▇▇▇.▇▇▇ and use the “BlueCard Doctor and Hospital Finder – Traditional Indemnity Network”. If you receive covered health care services from a non-network provider, you will be responsible for the provider’s charge. You will then be reimbursed based on the lesser of the provider’s charge, our allowance, or the maximum benefit limit less your deductible and copayments (if any). The deductible and maximum out-of-pocket expenses are calculated based on our allowance and not on the provider’s charge. See Section 7.1 for more information on how to file a claim. Below is a summary of our coverage levels under this Flex Plan Rider. It includes information about copayments, deductibles, and some benefit limits. This summary is intended to give you a general understanding of the coverage available under this Rider. For more detailed information, please read Section 3.0 for the description of coverage for each particular covered health care service along with the related exclusions and Section 5.0 for a list of general exclusions. *Preauthorization is recommended for this service. BlueCHiP providers are responsible for obtaining preauthorization for all applicable covered health care services. See Section 8.0 - definition of preauthorization for details. Deductible The amount you must pay each plan year before we begin to pay for certain covered health care services. See Glossary section for further details. The deductible accumulates separately for Care Coordinated plan services and Flex plan services. Services that apply the deductible are indicated in the Summary of Medical Benefits and the Summary of Pharmacy Benefits. Family plan deductible is met by adding the amount of covered health care expenses applied to the deductible for all family members; however no one (1) family member can contribute more than the amount shown in the Individual Plan deductible amount. Individual Plan: $3,000 Family Plan: $6,000 Individual Plan: $6,000 Family Plan: $12,000 Maximum Out-of-Pocket Expense The total combined amount of your deductible and copayments you must pay each plan year for certain covered health care services. See Glossary section for further details. The maximum out-of-pocket expense limit accumulates separately for Care Coordinated plan services and Flex plan services. The deductible and copayments (including, but not limited to, office visits copayments and prescription drug copayments) apply to the maximum out-of-pocket expense. The family maximum out-of-pocket expense limit is met by adding the amount of covered health care expenses applied to the maximum out-of-pocket expense limit for all family members, however no one family member can contribute more than the amount shown in the Individual Plan maximum out-of-pocket expense amount. Individual Plan: $6,850 Family Plan: $13,700 Individual Plan: $13,700 Family Plan: $27,400

Network Providers. If you seek covered health care services from a BlueCHiP provider, you will only be responsible for your deductible, copayment, and/or the difference between the maximum benefit and our allowance if any, which may apply to a covered health care service. To see if a provider is a BlueCHiP provider, check your BlueCHiP Coordinated Health Plan Provider Directory, call our Customer Service Department at (401) 274-3500 or ▇-▇▇▇-▇▇▇-▇▇▇▇ or TDD (▇▇▇) ▇▇▇-▇▇▇▇ or ▇-▇▇▇-▇▇▇-▇▇▇▇, or visit our Web site ▇▇▇▇▇▇▇▇.▇▇▇ If you are outside the local area you may seek covered health care services from a provider who participates with the BlueCard traditional indemnity network (a BlueCard provider). When you do so, you will only be responsible for your deductible, copayment, and/or the difference between the maximum benefit and the allowance (if any) based on the amount due under the BlueCard program policies. See Section 5.3 for more information on the BlueCard program. To see if a provider is a BlueCard provider, call BlueCard Access at the number shown on your BlueCHiP ID Card ▇-▇▇▇-▇▇▇ BLUE (2583) or visit ▇▇▇.▇▇▇▇.▇▇▇ and use the “BlueCard Doctor and Hospital Finder – Traditional Indemnity Network”. If you receive covered health care services from a non-network provider, you will be responsible for the provider’s charge. You will then be reimbursed based on the lesser of the provider’s charge, our allowance, or the maximum benefit limit less your deductible and copayments (if any). The deductible and maximum out-of-pocket expenses are calculated based on our allowance and not on the provider’s charge. See Section 7.1 for more information on how to file a claim. Below is a summary of our coverage levels under this Flex Plan Rider. It includes information about copayments, deductibles, and some benefit limits. This summary is intended to give you a general understanding of the coverage available under this Rider. For more detailed information, please read Section 3.0 for the description of coverage for each particular covered health care service along with the related exclusions and Section 5.0 for a list of general exclusions. *Preauthorization is recommended for this service. BlueCHiP providers are responsible for obtaining preauthorization for all applicable covered health care services. See Section 8.0 - definition of preauthorization for details. Deductible The amount you must pay each plan year before we begin to pay for certain covered health care services. See Glossary section for further details. The deductible accumulates separately for Care Coordinated plan services and Flex plan services. Services that apply the deductible are indicated in the Summary of Medical Benefits and the Summary of Pharmacy Benefits. Family plan deductible is met by adding the amount of covered health care expenses applied to the deductible for all family members; however no one (1) family member can contribute more than the amount shown in the Individual Plan deductible amount. Individual Plan: $3,000 5,000 Family Plan: $6,000 10,000 Individual Plan: $6,000 10,000 Family Plan: $12,000 20,000 Maximum Out-of-Pocket Expense The total combined amount of your deductible and copayments you must pay each plan year for certain covered health care services. See Glossary section for further details. The maximum out-of-pocket expense limit accumulates separately for Care Coordinated plan services and Flex plan services. The deductible and copayments (including, but not limited to, office visits copayments and prescription drug copayments) apply to the maximum out-of-pocket expense. The family maximum out-of-pocket expense limit is met by adding the amount of covered health care expenses applied to the maximum out-of-pocket expense limit for all family members, however no one family member can contribute more than the amount shown in the Individual Plan maximum out-of-pocket expense amount. Individual Plan: $6,850 Family Plan: $13,700 Individual Plan: $13,700 Family Plan: $27,400

Network Providers. If you seek covered health care services from a BlueCHiP provider, you will only be responsible for your deductible, copayment, and/or the difference between the maximum benefit and our allowance if any, which may apply to a covered health care service. To see if a provider is a BlueCHiP provider, check your BlueCHiP Coordinated Health Plan Provider Directory, call our Customer Service Department at (401) 274-3500 or ▇-▇▇▇-▇▇▇-▇▇▇▇ or TDD (▇▇▇) ▇▇▇-▇▇▇▇ or ▇-▇▇▇-▇▇▇-▇▇▇▇, or visit our Web site ▇▇▇▇▇▇▇▇.▇▇▇ If you are outside the local area you may seek covered health care services from a provider who participates with the BlueCard traditional indemnity network (a BlueCard provider). When you do so, you will only be responsible for your deductible, copayment, and/or the difference between the maximum benefit and the allowance (if any) based on the amount due under the BlueCard program policies. See Section 5.3 for more information on the BlueCard program. To see if a provider is a BlueCard provider, call BlueCard Access at the number shown on your BlueCHiP ID Card ▇-▇▇▇-▇▇▇ BLUE (2583) or visit ▇▇▇.▇▇▇▇.▇▇▇ and use the “BlueCard Doctor and Hospital Finder – Traditional Indemnity Network”. If you receive covered health care services from a non-network provider, you will be responsible for the provider’s charge. You will then be reimbursed based on the lesser of the provider’s charge, our allowance, or the maximum benefit limit less your deductible and copayments (if any). The deductible and maximum out-of-pocket expenses are calculated based on our allowance and not on the provider’s charge. See Section 7.1 for more information on how to file a claim. Below is a summary of our coverage levels under this Flex Plan Rider. It includes information about copayments, deductibles, and some benefit limits. This summary is intended to give you a general understanding of the coverage available under this Rider. For more detailed information, please read Section 3.0 for the description of coverage for each particular covered health care service along with the related exclusions and Section 5.0 for a list of general exclusions. *Preauthorization is recommended for this service. BlueCHiP providers are responsible for obtaining preauthorization for all applicable covered health care services. See Section 8.0 - definition of preauthorization for details. Deductible The amount you must pay each plan year before we begin to pay for certain covered health care services. See Glossary section for further details. The deductible accumulates separately for Care Coordinated plan services and Flex plan services. Services that apply the deductible are indicated in the Summary of Medical Benefits and the Summary of Pharmacy Benefits. Family plan deductible is met by adding the amount of covered health care expenses applied to the deductible for all family members; however however, no one (1) family member can contribute more than the amount shown in the Individual Plan deductible amount. Individual Plan: $3,000 Family Plan: $6,000 Individual Plan: $6,000 Family Plan: $12,000 Individual Plan: $10,000 Family Plan: $20,000 Maximum Out-of-Pocket Expense The total combined amount of your deductible and copayments you must pay each plan year for certain covered health care services. See Glossary section for further details. The maximum out-of-pocket expense limit accumulates separately for Care Coordinated plan services and Flex plan services. The deductible and copayments (including, but not limited to, office visits copayments and prescription drug copayments) apply to the maximum out-of-pocket expense. The family maximum out-of-pocket expense limit is met by adding the amount of covered health care expenses applied to the maximum out-of-pocket expense limit for all family members, however however, no one (1) family member can contribute more than the amount shown in the Individual Plan maximum out-of-of- pocket expense amount. Individual Plan: $6,850 Family Plan: $13,700 Individual Plan: $13,700 Family Plan: $27,400